AIS 2005/2008 Update Dictionary - Clarification Document ...

AIS 2005/2008 Update Dictionary - Clarification Document

Updated: 10/9/2019 15:16

We have combined and revised the clarification documents into an Excel file that has been saved as a PDF for viewing.

The first section is this "read me" area followed by: ALL of the combined items; General; Definitions; Rules-Guidelines; Head; Face; Neck; Thorax; Abdomen; Spine; Upper

Extremity; Lower Extremity; External; Other; Chart/Tables.

Although this is a PDF, you are still able to search the document.

We would like to take this opportunity to thank the AIS Faculty who worked on the development of the clarification documents over the years as well as those of you using the

coding system for your continued support, questions and suggestions!

ALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top

YEAR

CHAPTER

ITEM

DISCUSSION

10/9/2019 15:16

REFERENCE/EXAMPLE

2019

GENERAL

DEFINITION

Superficial Penetrating

Injury

(p.31) "Use one of the following

two descriptors when such vague

information, including traumatic

brain injury or closed head injury,

Coding rules and box bold directives have been integrated widely into the is the only information available.

dictionary where they apply to specific organs, structures, body regions or While these descriptors identify

at the beginning of each chapter to assist with accurate coding. Coders

the occurrence of a head injury,

should refer to them frequently.

they do not specify its severity."

Superficial penetrating injury skin/subcutaneous/muscle only without

underlying organ or bony involvement. For penetrating injuries to the

extremities that do not involve bone or vascular structures, code as minor

injury.

2019

GENERAL

DEFINITION

Asphyxia

Asphyxia definition is a condition arising when the body is deprived of

oxygen, causing unconsciousness or death. This is a codeable sequela.

(p.166)

2019

GENERAL

DEFINITION

Hemarthrosis

2019

HEAD

24 Hour Statement

Hemarthrosis is not a codable injury.

Within the first 24 hours post injury, patients with transient signs and

symptoms should be coded even if they are resolved within the 24 hour

period.

(p.40)

GENERAL

STATEMENT

THROUGHOUT

DICTIONARY

Using the Dictionary

2019

HEAD

Blood Along Tentorium

Supratentorial codes to Cerebrum; Interpeduncular fossa (cistern) basal

cisterns code as injury involving hemorrhage in the brainstem; "Along" the

tentorium, code to supratentorial = Cerebrum.

(p.41)

2019

HEAD

Amnesia

One symptom that can exist without a closed head injury, no AIS code.

2019

HEAD

Occipital Condyles

Occipital condyles are coded to the skull base.

2019

HEAD

Concussion

2019

HEAD

Coma Modifiers

(p.49)

Concussion must be documented in the medical record by a physician or

physician extender. Recorded in PI minutes is inadequate.

For codes with coma modifiers, "not associated with coma¡­" = means

there was documentation of coma, but it was not greater than 6 hours in

duration. "Associated with coma¡­." = means there was documentation of

coma, and it was greater than 6 hours in duration. The NFS code should e.g. SAH with coma 8 hours =

be used when there is no documentation of coma with an injury that has a 140695.3 SAH associated with

coma modifier.

coma > 6 hours

ALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top

ITEM

DISCUSSION

10/9/2019 15:16

YEAR

CHAPTER

REFERENCE/EXAMPLE

2019

FACE

LeFort Fractures

"LeFort" must be specified in the medical documentation to use the

LeFort fracture codes, otherwise, code individual fractured bones.

2019

FACE

Palate Perforation

Soft palate perforation code as laceration; hard palate perforation

code as fracture. If palate is not specified as soft or hard, code as fracture.

2019

NECK

Carotid Artery Injury

Carotid Artery injury not specified should be coded to Common Carotid

Artery.

(p.66)

2019

NECK

Jugular Vein Injury

2019

SPINE

24 Hour Statement

Jugular Vein injury not specified should be coded to Internal Jugular

Vein.

Within the first 24 hours post injury, patients with transient signs and

symptoms should be coded even if they are resolved within the 24 hour

period.

2019

UP EXTREM

Rotator Cuff

Rotator cuff should be assigned to Shoulder, Glenohumeral Joint, NFS

(771099.1)

2019

EXTERNAL

Skin Tears

Skin tears are coded as a laceration to the appropriate location on the

patient and assigned to the ISS body region for calculating an ISS.

2019

OTHER

Hanging/Drowning Deaths

2019

OTHER

Hypothermia

2016

GENERAL

DEFINITION

Puncture Wound

Puncture wound is caused by spearing or impalement type injuries.

These should be coded as Penetrating NFS or Penetrating minor

superficial

2016

GENERAL

DEFINITION

Palsy/Paresis

Palsy/Paresis are coded as nerve contusion.

2016

GENERAL

DEFINITION

Paralysis/Total Loss of

Function

Paralysis or Total Loss of Function is coded as nerve laceration.

2016

GENERAL

DEFINITION

Incomplete Transection

Incomplete transection is the same as incomplete circumferential

involvement.

2016

GENERAL

DEFINITION

Pseudoaneurysm

Pseudoaneurysm is coded as a minor artery laceration.

(p.68)

(p.100)

(p.121)

Hanging/Drowning deaths with medical examiner's diagnosis counts as

"cardiac arrest documented by medical personnel".

(p.166)

Hypothermia is coded in whole number temperature only; do not round up

or down. Codes for Fahrenheit are:

(p.167)

ALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top

YEAR

CHAPTER

2016

GENERAL

DEFINITION

ITEM

DISCUSSION

Amputation

Amputation is defined as "traumatic" not surgical

2016

GENERAL

DEFINITION

Morel Lavalle Lesion

Morel Lavalle Lesion , internal shearing or degloving injury of an

extremity is coded as a degloving injury in the appropriate extremity

chapter.

2016

GENERAL

DEFINITION

Micro Fractures

Micro fractures are not a codeable injuries.

2016

GENERAL

DEFINITION

Bone Contusions

Bone contusions are not a codeable injuries.

2016

GENERAL

DEFINITION

Bone Edema

Bone edema is not a codeable injury.

2016

GENERAL

DEFINITION

Extra-Articular

Complete Articular

Extra-Articular refers to a fracture with NO joint involvement.

Partial Articular (Intra-Articular) refers to at least one fracture through

the joint surface and part of the articular surface is still in continuity with

the diaphysis.

Complete Articular refers to a fracture where the articular surface is

fractured AND there is no continuity with the diaphysis.

Acute on Chronic Bleeds

If the clinician does not differentiate and document the acute from chronic

bleed, code as NFS in the appropriate section.

Pterygoid Plates are part of the sphenoid bone and are coded to the

base of the skull if injured in isolation. If the pterygoid plates are part of a

LeFort fracture, they are NOT coded additionally as skull base fractures.

2016

GENERAL

DEFINITION

GENERAL

DEFINITION

2016

HEAD

2016

Partial Articular

2016

HEAD

Pterygoid Plates

2016

FACE

Caustic Injury

2016

NECK

Thrombosis (Occlusion)

SPINE

Spinal Cord Injury with

Associated Fracture, no

deficit

2016

2016

SPINE

Pars Interarticularis

2016

THORAX

Persistent Air Leak

Caustic injury to the mouth is coded as 243099.1

Thrombosis (occlusion) secondary to trauma from any lesion but

laceration (under carotid artery, internal, and external, and vertebral

artery) refers to the sequela of blunt trauma to neck.

Spinal cord injury such as compression, epidural or subdural hemorrhage

associated with a fracture AND there is NO neurologic deficit, the coder

must choose to either code the cord injury OR the fracture. Current rules

prohibit coding both.

10/9/2019 15:16

REFERENCE/EXAMPLE

Refer to drawings in the upper

and lower extremity chapters

Refer to drawings in the upper

and lower extremity chapters

(p.58)

Example: seatbelt injury

Pars interarticularis is located between the lamina and the pedicle

anatomically and should be coded as pedicle. Previous teaching of coding

this to LAMINA has been changed per recent Neurosurgery input.

Persistent Air Leak (442203.4) is described as an air leak in the thorax

that lasts for more than 48 hours, which represents a more severe injury

than a simple pneumothorax.

(p.81)

ALL - AIS 2005/2008 Update Dictionary - Clarification Document - Most Current Clarification Date At the Top

YEAR

CHAPTER

2016

THORAX

ITEM

DISCUSSION

10/9/2019 15:16

REFERENCE/EXAMPLE

Intracardiac Septum

Intracardiac Septum may also be identified as "intraventricular" septum. (p.78)

Flail Chest

Flail chest with additional but separate rib fractures on the same

side is coded to the more severe injury, the flail chest, and the additional

rib fractures on the same side are not coded.

2016

THORAX

2016

ABDOMEN

Hemoperitoneum

Hemoperitoneum is a sequela and is not a codeable injury.

2016

ABDOMEN

Serosal Tear

Serosal tear is coded as a partial thickness injury.

2016

UP EXTREM

Digital Vessels

Digital vessels are included in "other named vessels"

2016

LOW EXTREM

Hip Fracture

"Hip Fracture" simply stated with no other description is coded as a

proximal femur fracture (853111.3)

(p.147)

2016

LOW EXTREM

Slipped Epiphysis

Slipped Epiphysis in children is coded as a femur neck fracture

(853161.3)

(p.147)

2016

OTHER

Caustic Injury

Caustic injury (040099.9) is only used if the specific location is not

known.

(p.166)

2013

GENERAL

DEFINITION

Vessel Dissection

Vessel dissection should be coded to intimal tear for all vessels

including descriptors for carotid artery common/internal, carotid artery

external and vertebral artery.

2013

GENERAL

DEFINITION

Internal Carotid Artery

May refer to either AIS Head or Neck Chapters . AIS Head codes

121099.3 to 121006.3 "Internal Carotid Artery" and 320099.9 to 320223.4

"Carotid Artery". When the exact location of the injury is not specified as to

head or neck, code to the neck region with applicable associated detail

(laceration, thrombosis, occlusion, etc.)

2013

GENERAL

DEFINITION

External Carotid Artery

See also Face Chapter which includes branches of the external carotid

artery.

Vertebral Artery

May refer to either AIS Head or Neck Chapters. When the exact

location of the injury is not specified as to head or neck, code to the neck

region with applicable associated detail (laceration, thrombosis, occlusion,

etc.)

Multiple hematomas/SDH

small or Large, same

hemisphere

When multiple small (140640.4) or large (140648.5) hematomas OR when

multiple small (140652.4) or large (140656.5) SDH are diagnosed, code

each individually IF they are separate and individual hematomas/bleeds of

the same (unilateral) hemisphere. If both hemispheres are involved use

the bilateral code.

2013

2013

GENERAL

DEFINITION

HEAD

(p.82)

e.g. 2 codes would be required

Small (L) frontal SDH = 140652.4

Small (L) occipital SDH =

140652.4

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download